Do-(Not-)Mechanical-Circulatory-Support Orders: Should We Ask All Cardiac Surgery Patients for Informed Consent for Post-Cardiotomy Extracorporeal Life Circulatory Support?

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Abstract

Post-cardiotomy extracorporeal life support (PC-ECLS) has seen a substantial increase in use over the past 10 years. PC-ECLS can be a life-saving procedure and is mostly applied in the presence of unexpected, severe cardio-respiratory complication. Despite PC-ECLS being critical in allowing for organ recovery, it is unfortunately closely connected with an unpredictable outcomes, high morbidity, and, even in the case of cardiac function improvement, potential sustained disabilities that have a life-changing impact for the patient and his or her family. Since the decision to start PC-ECLS is made in an acute setting, there is often only limited or no time for self-determined choices. Due to the major impact of the intervention, it would be highly desirable to obtain informed consent before starting PC-ECLS, since the autonomy of the patient and shared-decision making are two of the most important ethical values in modern medicine. Recent developments regarding awareness of the impacts of a prolonged intensive care stay make this a particularly relevant topic. Therefore, it would be desirable to develop a structural strategy that takes into account the likelihood of such an intervention and the wishes and preferences of the patient, and thus the related autonomy of the patient. This article proposes key points for such a strategy in the form of a PC-ECLS informed consent, a do-(not-)mechanical-circulatory-support order (D(N)MCS), and specific guidelines to determine the extent of the shared decision making. The concept presented in this article could be a starting point for improved and ethical PC-ECLS treatment and application.

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The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome

Matthieu Schmidt, Elie Zogheib, Hadrien Roze … (2013)

Purpose This study was designed to identify factors associated with death by 6 months post-intensive care unit (ICU) discharge and to develop a practical mortality risk score for extracorporeal membrane oxygenation (ECMO)-treated acute respiratory distress syndrome (ARDS) patients. We also assessed long-term survivors’ health-related quality of life (HRQL), respiratory symptoms, and anxiety, depression and post-traumatic stress disorder (PTSD) frequencies. Methods Data from 140 ECMO-treated ARDS patients admitted to three French ICUs (2008–2012) were analyzed. ICU survivors contacted >6 months post-ICU discharge were assessed for HRQL, psychological and PTSD status. Results Main ARDS etiologies were bacterial (45 %), influenza A[H1N1] (26 %) and post-operative (17 %) pneumonias. Six months post-ICU discharge, 84 (60 %) patients were still alive. Based on multivariable logistic regression analysis, the PRESERVE (PRedicting dEath for SEvere ARDS on VV-ECMO) score (0–14 points) was constructed with eight pre-ECMO parameters, i.e. age, body mass index, immunocompromised status, prone positioning, days of mechanical ventilation, sepsis-related organ failure assessment, plateau pressure andpositive end-expiratory pressure. Six-month post-ECMO initiation cumulative probabilities of survival were 97, 79, 54 and 16 % for PRESERVE classes 0–2, 3–4, 5–6 and ≥7 (p < 0.001), respectively. HRQL evaluation in 80 % of the 6-month survivors revealed satisfactory mental health but persistent physical and emotional-related difficulties, with anxiety, depression or PTSD symptoms reported, by 34, 25 or 16 %, respectively. Conclusions The PRESERVE score might help ICU physicians select appropriate candidates for ECMO among severe ARDS patients. Future studies should also focus on physical and psychosocial rehabilitation that could lead to improved HRQL in this population. Electronic supplementary material The online version of this article (doi:10.1007/s00134-013-3037-2) contains supplementary material, which is available to authorized users.

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Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality. Analysis of the extracorporeal life support organization registry.

Ryan P Barbaro, Folafoluwa Odetola, Kelley Kidwell … (2015)

Recent pediatric studies suggest a survival benefit exists for higher-volume extracorporeal membrane oxygenation (ECMO) centers. To determine if higher annual ECMO patient volume is associated with lower case-mix-adjusted hospital mortality rate. We retrospectively analyzed an international registry of ECMO support from 1989 to 2013. Patients were separated into three age groups: neonatal (0-28 d), pediatric (29 d to <18 yr), and adult (≥18 yr). The measure of hospital ECMO volume was age group-specific and adjusted for patient-level case-mix and hospital-level variance using multivariable hierarchical logistic regression modeling. The primary outcome was death before hospital discharge. A subgroup analysis was conducted for 2008-2013. From 1989 to 2013, a total of 290 centers provided ECMO support to 56,222 patients (30,909 neonates, 14,725 children, and 10,588 adults). Annual ECMO mortality rates varied widely across ECMO centers: the interquartile range was 18-50% for neonates, 25-66% for pediatrics, and 33-92% for adults. For 1989-2013, higher age group-specific ECMO volume was associated with lower odds of ECMO mortality for neonates and adults but not for pediatric cases. In 2008-2013, the volume-outcome association remained statistically significant only among adults. Patients receiving ECMO at hospitals with more than 30 adult annual ECMO cases had significantly lower odds of mortality (adjusted odds ratio, 0.61; 95% confidence interval, 0.46-0.80) compared with adults receiving ECMO at hospitals with less than six annual cases. In this international, case-mix-adjusted analysis, higher annual hospital ECMO volume was associated with lower mortality in 1989-2013 for neonates and adults; the association among adults persisted in 2008-2013.

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Quality of life in adult survivors of critical illness: a systematic review of the literature.

David Dowdy, Mark P Eid, Artyom Sedrakyan … (2005)

To determine how the quality of life (QOL) of intensive care unit (ICU) survivors compares with the general population, changes over time, and is predicted by baseline characteristics. Systematic literature review including MEDLINE, EMBASE, CINAHL and Cochrane Library. Eligible studies measured QOL > or = 30 days after ICU discharge using the Medical Outcomes Study 36-item Short Form (SF-36), EuroQol-5D, Sickness Impact Profile, or Nottingham Health Profile in representative populations of adult ICU survivors. Disease-specific studies were excluded. Of 8,894 citations identified, 21 independent studies with 7,320 patients were reviewed. Three of three studies found that ICU survivors had significantly lower QOL prior to admission than did a matched general population. During post-discharge follow-up, ICU survivors had significantly lower QOL scores than the general population in each SF-36 domain (except bodily pain) in at least four of seven studies. Over 1-12 months of follow-up, at least two of four studies found clinically meaningful improvement in each SF-36 domain except mental health and general health perceptions. A majority of studies found that age and severity of illness predicted physical functioning. Compared with the general population, ICU survivors report lower QOL prior to ICU admission. After hospital discharge, QOL in ICU survivors improves but remains lower than general population levels. Age and severity of illness are predictors of physical functioning. This systematic review provides a general understanding of QOL following critical illness and can serve as a standard of comparison for QOL studies in specific ICU subpopulations.

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Author and article information

Contributors

Lakshmi Raman: Role: Academic Editor

Melissa E. Brunsvold: Role: Academic Editor

Journal

Journal ID (nlm-ta): J Clin Med

Journal ID (iso-abbrev): J Clin Med

Journal ID (publisher-id): jcm

Title: Journal of Clinical Medicine

Publisher: MDPI

ISSN (Electronic): 2077-0383

Publication date (Electronic): 20 January 2021

Publication date Collection: February 2021

Volume: 10

Issue: 3

Electronic Location Identifier: 383

Affiliations

[1 ]Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; jorik.simons@ 123456mumc.nl (J.S.); j.g.maessen@ 123456mumc.nl (J.M.)

[2 ]Department of Intensive Care Medicine, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; martje.suverein@ 123456mumc.nl (M.S.); w.van.mook@ 123456mumc.nl (W.v.M.); marcel.vande.poll@ 123456mumc.nl (M.v.d.P.); thijs.delnoij@ 123456mumc.nl (T.D.)

[3 ]School of Health Professions Education, Maastricht University, 6229 ER Maastricht, The Netherlands

[4 ]Academy for Postgraduate Medical Training, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands

[5 ]Department of Cardiology, Heart Failure, Heart Transplantation and Mechanical Circulatory Support, Erasmus Medical Centre, 3015 GD Rotterdam, The Netherlands; k.caliskan@ 123456erasmusmc.nl

[6 ]Department of Cardiology, School of Medicine, National University of Ireland, H91 TK33 Galway, Ireland; osama.soliman@ 123456nuigalway.ie

[7 ]Department of Surgery, NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands

[8 ]Department of Cardiology, CARIM School for Cardiovascular Diseases, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands

[9 ]Department of Vascular Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC+), 6229 HX Maastricht, The Netherlands; barend.mees@ 123456mumc.nl

Author notes

[* ]Correspondence: roberto.lorussobs@ 123456gmail.com

Author information

Osama Soliman https://orcid.org/0000-0003-0758-3539

Marcel van de Poll https://orcid.org/0000-0002-3302-4063

Barend Mees https://orcid.org/0000-0001-6545-5813

Roberto Lorusso https://orcid.org/0000-0002-1777-2045

Article

Publisher ID: jcm-10-00383

DOI: 10.3390/jcm10030383

PMC ID: 7864157

PubMed ID: 33498412

SO-VID: aeed8449-46cb-479b-bf26-5c141c2fa5fe

License:

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

Do-(Not-)Mechanical-Circulatory-Support Orders: Should We Ask All Cardiac Surgery Patients for Informed Consent for Post-Cardiotomy Extracorporeal Life Circulatory Support?

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Most cited references 55

The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome

Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality. Analysis of the extracorporeal life support organization registry.

Quality of life in adult survivors of critical illness: a systematic review of the literature.

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